{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,17]],"date-time":"2026-10-17T19:37:10Z","timestamp":1792265830477,"version":"4.4.0"},"reference-count":55,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2021,9,15]],"date-time":"2021-09-15T00:00:00Z","timestamp":1631664000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: The aim of this review was to assess the quality of international treatment guidelines for post-traumatic stress disorder (PTSD), and identify differences between guideline recommendations, with a focus on the treatment of nightmares. Methods: Guidelines were identified through electronic searches of MEDLINE, CINAHL, PubMed, Embase and Science Direct, as well as web-based searches of international guideline repositories, websites of psychiatric organisations and targeted web-searches for guidelines from the three most populous English-speaking countries in each continent. Data in relation to recommendations were extracted and the AGREE II criteria were applied to assess for quality. Results: Fourteen guidelines, published between 2004\u20132020, were identified for inclusion in this review. Only five were less than 5 years old. Three guidelines scored highly across all AGREE II domains, while others varied between domains. Most guidelines consider both psychological and pharmacological therapies as first-line in PTSD. All but one guideline recommended cognitive behavioural therapy (CBT) as first-line psychological treatment, and selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment. Most guidelines do not mention the targeted treatment of nightmares as a symptom of PTSD. Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations vary widely. Most PTSD guidelines were deemed to be of good quality; however, many could be considered out of date. Recommendations for core PTSD symptoms do not differ greatly between guidelines. However, despite the availability of targeted treatments for nightmares, most guidelines do not adequately address this. Conclusions: Guidelines need to be kept current to maintain clinical utility. Improvements are most needed in the AGREE II key domains of \u2018applicability\u2019, \u2018rigour of development\u2019 and \u2018stakeholder involvement\u2019. Due to the treatment-resistant nature of nightmares, guideline development groups should consider producing more detailed recommendations for their targeted treatment. More high-quality trials are also required to provide a solid foundation for making these clinical recommendations for the management of nightmares in PTSD.<\/jats:p>","DOI":"10.3390\/jcm10184175","type":"journal-article","created":{"date-parts":[[2021,9,15]],"date-time":"2021-09-15T12:00:44Z","timestamp":1631707244000},"page":"4175","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":165,"title":["Treatment Guidelines for PTSD: A Systematic Review"],"prefix":"10.3390","volume":"10","author":[{"given":"Alicia","family":"Martin","sequence":"first","affiliation":[{"name":"Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6422-7170","authenticated-orcid":false,"given":"Mark","family":"Naunton","sequence":"additional","affiliation":[{"name":"Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6737-1442","authenticated-orcid":false,"given":"Sam","family":"Kosari","sequence":"additional","affiliation":[{"name":"Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6764-3882","authenticated-orcid":false,"given":"Gregory","family":"Peterson","sequence":"additional","affiliation":[{"name":"Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia"},{"name":"School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jackson","family":"Thomas","sequence":"additional","affiliation":[{"name":"Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia K.","family":"Christenson","sequence":"additional","affiliation":[{"name":"Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,9,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1016\/j.cpr.2009.08.006","article-title":"Posttraumatic stress disorder and quality of life: Extension of findings to veterans of the wars in Iraq and Afghanistan","volume":"29","author":"Schnurr","year":"2009","journal-title":"Clin. Psychol. Rev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e60991","DOI":"10.1371\/journal.pone.0060991","article-title":"Symptoms and subjective quality of life in post-traumatic stress disorder: A longitudinal study","volume":"8","author":"Giacco","year":"2013","journal-title":"PLoS ONE"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1080\/15299732.2016.1141150","article-title":"Meta-analysis of the efficacy and safety of prazosin versus placebo for the treatment of nightmares and sleep disturbances in adults with posttraumatic stress disorder","volume":"17","author":"George","year":"2016","journal-title":"J. Trauma Dissociation Off. J. Int. Soc. Study Dissociation (ISSD)"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1171","DOI":"10.1176\/appi.ajp.162.6.1171","article-title":"Quality-of-life impairment in depressive and anxiety disorders","volume":"162","author":"Rapaport","year":"2005","journal-title":"Am. J. Psychiatry"},{"key":"ref_5","first-page":"4","article-title":"Posttraumatic stress disorder: The burden to the individual and to society","volume":"61","author":"Kessler","year":"2000","journal-title":"J. Clin. Psychiatry"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/S0163-8343(00)00080-3","article-title":"Posttraumatic stress disorder in the primary care medical setting","volume":"22","author":"Stein","year":"2000","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1002\/jts.22010","article-title":"Types and Number of Traumas Associated With Suicidal Ideation and Suicide Attempts in PTSD: Findings From a U.S. Nationally Representative Sample","volume":"28","author":"LeBouthillier","year":"2015","journal-title":"J. Trauma. Stress"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5, American Psychiatric Publishing. [5th ed.].","DOI":"10.1176\/appi.books.9780890425596"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1093\/sleep\/30.1.91","article-title":"Nightmares and sleep disturbances in relation to suicidality in suicide attempters","volume":"30","author":"Sjostrom","year":"2007","journal-title":"Sleep"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.genhosppsych.2015.10.007","article-title":"Prazosin for treating sleep disturbances in adults with posttraumatic stress disorder: A systematic review and meta-analysis of randomized controlled trials","volume":"39","author":"Khachatryan","year":"2016","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.smrv.2007.08.008","article-title":"Disturbed sleep in post-traumatic stress disorder: Secondary symptom or core feature?","volume":"12","author":"Spoormaker","year":"2008","journal-title":"Sleep Med. Rev."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Katz, C., Stein, M., Richardson, J., Seedat, S., and Sareen, J. (2011). A Review of Interventions for Treatment-Resistant Posttraumatic Stress Disorder. Different Views of Anxiety Disorders, IntechOpen.","DOI":"10.5772\/23234"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Detweiler, M.B., Pagadala, B., Candelario, J., Boyle, J.S., Detweiler, J.G., and Lutgens, B.W. (2016). Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center. J. Clin. Med., 5.","DOI":"10.3390\/jcm5120117"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"11","DOI":"10.5664\/jcsm.4354","article-title":"Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress","volume":"11","author":"Seda","year":"2015","journal-title":"J. Clin. Sleep Med."},{"key":"ref_15","unstructured":"Therapeutic Guidelines Limited (2013). Posttraumatic Mental Health Disorders, Therapeutic Guidelines Limited."},{"key":"ref_16","unstructured":"Phoenix Australia Centre for Posttraumatic Mental Health (2020). Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder, and Complex Posttraumatic Stress Disorder, National Health and Medical Research Council."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1136\/bmj.318.7182.527","article-title":"Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines","volume":"318","author":"Woolf","year":"1999","journal-title":"BMJ"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1093\/intqhc\/mzv115","article-title":"Guide to clinical practice guidelines: The current state of play","volume":"28","author":"Kredo","year":"2016","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1581","DOI":"10.1001\/jamainternmed.2013.7672","article-title":"Why don\u2019t physicians (and patients) consistently follow clinical practice guidelines?","volume":"173","author":"Casey","year":"2013","journal-title":"JAMA Intern. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/1748-5908-8-6","article-title":"Developing and evaluating communication strategies to support informed decisions and practice based on evidence (DECIDE): Protocol and preliminary results","volume":"8","author":"Treweek","year":"2013","journal-title":"Implement. Sci."},{"key":"ref_21","first-page":"186","article-title":"Usefulness and limitations of treatment guidelines in psychiatry","volume":"1","author":"McIntyre","year":"2002","journal-title":"World Psychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/1471-244X-10-8","article-title":"Implementing clinical guidelines in psychiatry: A qualitative study of perceived facilitators and barriers","volume":"10","author":"Forsner","year":"2010","journal-title":"BMC Psychiatry"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Barbui, C., Girlanda, F., Ay, E., Cipriani, A., Becker, T., and Koesters, M. (2014). Implementation of treatment guidelines for specialist mental health care. Cochrane Database Syst. Rev.","DOI":"10.1002\/14651858.CD009780.pub2"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e1000097","DOI":"10.1371\/journal.pmed.1000097","article-title":"Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement","volume":"6","author":"Moher","year":"2009","journal-title":"PLoS Med."},{"key":"ref_25","unstructured":"Martin, A., Naunton, M., Kosari, S., Peterson, G., Thomas, J., and Christiensen, J. (2021, July 17). Systematic Review of International Treatment Guidelines for PTSD. PROSPERO 2017 CRD42017084122. Available online: https:\/\/www.crd.york.ac.uk\/prospero\/display_record.php?ID=CRD42017084122."},{"key":"ref_26","unstructured":"McFetridge, M., Swan, A.H., Heke, S., Karatzias, T., Greenberg, N., Kitchiner, N., and Morley, R. (2017). Guideline for the Treatment and Planning of Services for Complex Post-Traumatic Stress Disorder in Adults, UK Psychological Trauma Society. Available online: https:\/\/ray.yorksj.ac.uk\/id\/eprint\/4862\/."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"E839","DOI":"10.1503\/cmaj.090449","article-title":"AGREE II: Advancing guideline development, reporting and evaluation in health care","volume":"182","author":"Brouwers","year":"2010","journal-title":"CMAJ"},{"key":"ref_28","first-page":"3","article-title":"Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder","volume":"161","author":"Ursano","year":"2004","journal-title":"Am. J. Psychiatry"},{"key":"ref_29","unstructured":"Canadian Psychiatric Association (2006). Clinical practice guidelines. Management of anxiety disorders. Can. J. Psychiatry Rev. Can. De Psychiatr., 51, 9S\u201391S."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1080\/15622970802465807","article-title":"World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders\u2014first revision","volume":"9","author":"Bandelow","year":"2008","journal-title":"World J. Biol. Psychiatry"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Standards of Practice Committee, Aurora, R.N., Zak, R.S., Auerbach, S.H., Casey, K.R., Chowdhuri, S., Karippot, A., Maganti, R.K., Ramar, K., and Kristo, D.A. (2010). Best practice guide for the treatment of nightmare disorder in adults. J. Clin. Sleep Med., 6, 389\u2013401.","DOI":"10.5664\/jcsm.27883"},{"key":"ref_32","unstructured":"World Health Organisation (2013). Guidelines for the Management of Conditions Specifically Related to Stress, World Health Organization."},{"key":"ref_33","first-page":"134","article-title":"The South African Society of Psychiatrists (SASOP) Treatment Guidlelines for Psychiatric Disorders","volume":"19","author":"Emsley","year":"2013","journal-title":"S. Afr. J. Psychiatry"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1186\/1471-244X-14-S1-S1","article-title":"Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders","volume":"14","author":"Katzman","year":"2014","journal-title":"BMC Psychiatry"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1177\/0269881114525674","article-title":"Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology","volume":"28","author":"Baldwin","year":"2014","journal-title":"J. Psychopharmacol. Oxf. Engl."},{"key":"ref_36","unstructured":"Department of Veterans Affairs, Department of Defense (2017). VA\/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder."},{"key":"ref_37","unstructured":"Guideline Development Panel for the Treatment of PTSD in Adults, Courtois, C., Sonis, J., Brown, L.S., Cook, J., Fairbank, J.A., Friedman, M., Gone, J.P., Jones, R., and La Greca, A. (2017). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults, American Pyschological Association."},{"key":"ref_38","unstructured":"National Institute for Health and Care Excellence (NICE) (2018). Post-Traumatic Stress Disorder, National Institute for Health and Care Excellence (NICE)."},{"key":"ref_39","unstructured":"Forbes, D., Bisson, J., Monson, C., and Berliner, L. (2020). Effective Treatments for PTSD, Third Edition: International Society for Traumatic Stress Studies, Guilford Press."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1461","DOI":"10.1001\/jama.286.12.1461","article-title":"Validity of the agency for healthcare research and quality clinical practice guidelines: How quickly do guidelines become outdated?","volume":"286","author":"Shekelle","year":"2001","journal-title":"JAMA"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1177\/0194599815573735","article-title":"Updating Clinical Practice Guidelines: How Do We Stay Current?","volume":"153","author":"Richard","year":"2015","journal-title":"Otolaryngol.-Head Neck Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1136\/bmj.323.7305.155","article-title":"When should clinical guidelines be updated?","volume":"323","author":"Shekelle","year":"2001","journal-title":"BMJ"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1192\/bjp.bp.114.148551","article-title":"Pharmacotherapy for post-traumatic stress disorder: Systematic review and meta-analysis","volume":"206","author":"Hoskins","year":"2015","journal-title":"Br. J. Psychiatry"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"e0126529","DOI":"10.1371\/journal.pone.0126529","article-title":"Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis","volume":"10","author":"Puetz","year":"2015","journal-title":"PLoS ONE"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"792","DOI":"10.1002\/da.22511","article-title":"Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: Systematic review and meta-analyses to determine first-line treatments","volume":"33","author":"Lee","year":"2016","journal-title":"Depress. Anxiety"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"241","DOI":"10.2190\/PM.38.3.b","article-title":"A Systematic Review on the Effectiveness of Cognitive Behavioral Therapy for Posttraumatic Stress Disorder","volume":"38","author":"Mendes","year":"2008","journal-title":"Int. J. Psychiatry Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1097\/NMD.0000000000000306","article-title":"Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: Systematic review and meta-analysis","volume":"203","author":"Chen","year":"2015","journal-title":"J. Nerv. Ment. Dis."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1094","DOI":"10.2174\/1389450116666150506114108","article-title":"Targeting the noradrenergic system in posttraumatic stress disorder: A systematic review and meta-analysis of prazosin trials","volume":"16","author":"Berardis","year":"2015","journal-title":"Curr. Drug Targets"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"e2603","DOI":"10.17795\/ijpbs-2603","article-title":"Prazosin for Trauma Nightmares and Sleep Disturbances in Combat Veterans with Post-Traumatic Stress Disorder","volume":"10","author":"Khazaie","year":"2016","journal-title":"Iran. J. Psychiatry Behav. Sci."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1056\/NEJMoa1507598","article-title":"Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans","volume":"378","author":"Raskind","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1056\/NEJMe1716724","article-title":"Alpha-Adrenergic Receptors in PTSD\u2014Failure or Time for Precision Medicine?","volume":"378","author":"Ressler","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e013881","DOI":"10.1136\/bmjopen-2016-013881","article-title":"Pharmacological guidelines for schizophrenia: A systematic review and comparison of recommendations for the first episode","volume":"7","author":"Keating","year":"2017","journal-title":"BMJ Open"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1192\/bjp.187.3.248","article-title":"Schizophrenia practice guidelines: International survey and comparison","volume":"187","author":"Gaebel","year":"2005","journal-title":"Br. J. Psychiatry"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.jad.2014.11.032","article-title":"Rigour of development of clinical practice guidelines for the pharmacological treatment of bipolar disorder: Systematic review","volume":"174","author":"Castellani","year":"2015","journal-title":"J. Affect. Disord."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"e31","DOI":"10.1111\/j.1463-1318.2011.02765.x","article-title":"A systematic review of treatment guidelines for metastatic colorectal cancer","volume":"14","author":"Edwards","year":"2012","journal-title":"Colorectal Dis."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/18\/4175\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:00:15Z","timestamp":1760166015000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/18\/4175"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,9,15]]},"references-count":55,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2021,9]]}},"alternative-id":["jcm10184175"],"URL":"https:\/\/doi.org\/10.3390\/jcm10184175","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,9,15]]}}}